Your Role

The Risk Adjustment Provider Partnership team supports all functions within the risk adjustment program, working with cross-functional teams at Blue Shield and Provider Groups. The Risk Adjustment Consultant, reporting to the Manager, will work with operational and clinical leaders to improve recapture rates, understand clinical suspects, and monitor documentation and coding accuracy. They will also implement Blue Shield Programs that ensure diagnoses are coded according to CMS and risk adjustment guidelines. The ideal candidate has strong customer service, project management, organizational, and analytical skills, is a self-starter, and pays high attention to detail. They may assemble project teams, assign and monitor work, and provide guidance and leadership.

Your Work

In this role, you will:

• Make recommendations based on understanding the core principles and functionality of decision, descriptive, predictive, and prescriptive analytic methods
• Train lower-level staff on how to update and apply these advanced analytic techniques
• Drive leadership, guidance, and manage all aspects of a given program, including vendor oversight, internal cross-functional partnerships, tracking performance and measuring results
• Manage data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals
• Manage the development and implementation of process of company's projects involving departmental or cross-functional teams focused on delivery of new or existing internal/external programs and/or products
• Collaborate with provider groups to enhance their risk adjustment processes by creating tailored plans to boost RAF performance and improve coding specificity
• Assisting provider groups in comprehending the various risk adjustment models, with a particular focus on the Medi-Cal CPDS+Rx model as it pertains to payment methodology. This includes guidance on claims and encounter submissions and the critical importance of accurate chart documentation for procedures and diagnosis coding
• Collaborates with Risk Adjustment Provider Partnership Management and Quality teams to formulate and implement comprehensive risk adjustment strategies
• Use analytics to identify training opportunities and collaborate with providers to clarify missing or inadequate information for determining appropriate diagnostic and procedure codes
• Works closely with Analytics team to drive analysis to forecast and evaluate the performance of the BSC Risk Adjustment Programs and refine annul risk adjustment strategies to achieve optimal performance

Your Knowledge and Experience

• Requires a bachelor's degree
• Requires at least 6 years of professional experience
• Requires deep knowledge of job area obtained through professional experience and advanced education
• Requires knowledge of ICD-10 codes, Risk Adjustment models, Medicare Quality/Stars, analytics/finance, provider contracting, provider relations, medical management and/or provider network management areas of a healthcare-related company
• Requires 5 years of experience in facilitating meetings, presenting risk adjustment metrics, and driving results.
• Requires 5 years of developing analytic reporting insights into risk adjustment improvement and business/financial challenges
• Requires a thorough understanding of clinical metrics, claims/encounters and risk adjustment analytics
• Requires proficiency in Excel, Word, PowerPoint, and Outlook
• Masters degree is preferred

Pay Range

The pay range for this role is: $ 118800.00 to $ 178200.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.